Saving Mothers Perspective

Use of Butterfly iQ During COVID-19 Pandemic in NYC
A Case Study by
Original Research by
Rachel Wong
Noel Strong MD
Taraneh Shirazian
,
and
and
“Using Butterfly iQ at the bedside minimized the need to transfer patients, reducing COVID-19 exposure while still allowing us to provide quality OB care.”

Introduction

The SARS-CoV2 (COVID-19) outbreak has spread at an unprecedented rate, resulting in over 1.2 million deaths worldwide. The challenge to contain COVID-19 continues to overwhelm healthcare systems, rendering nosocomial transmission to patients and healthcare workers a major public health focus. While ultrasound is an important diagnostic tool for pulmonary, hemodynamic, and obstetric conditions, minimizing exposure via use of routine imaging is central to reduction of COVID-19 transmission.¹ Handheld ultrasounds have proven beneficial, as they provide similar diagnostic ability to non-portable ultrasounds and can be decontaminated more easily.¹ The Butterfly iQ, a handheld ultrasound, was used to assess two high-risk  pregnancies for COVID-19 positive patients in a NYC hospital during the peak of the pandemic. 

Background 

While it was once limited to obstetrics and echocardiography, ultrasound technology is becoming increasingly utilized in nearly all medical fields.² Its usage ranges from diagnosis of hemodynamic conditions, to pericardial or pleural effusion, to intra-abdominal fluid. Advantages of ultrasound include its relatively low cost, portability, user-friendliness, and minimal radiation exposure for patients and clinicians. ²,³

The Butterfly iQ is part of a new generation of hand-held, portable ultrasound devices. It  utilizes thousands of metal drums on a silicon chip that both receive and produce sound waves.⁴ Images received via the Butterfly iQ’s silicon chip, can be viewed on the  Butterfly iQ app on mobile devices.⁴ The Butterfly iQ’s chip-based design allows it to feature a variety of presets that automatically adjust scan settings for optimal images based on the system being examined. In addition, it can perform simple size and surface area calculations, and features an obstetric calculations package.⁴ The ultrasound findings can be saved to the Butterfly Cloud, allowing other experts to examine the images, collaborate and comment.⁵ Most importantly, it costs $1,999 per probe, while traditional machines can range from  $25,000 to $250,000.³  

The low cost, portability, and varied clinical use cases of the Butterfly iQ  has spurred interest in using it in low- and middle-income countries to improve prenatal care and reduce maternal mortality. Limited access to obstetric ultrasound in developing countries is a significant contributor to negative maternal and neonatal outcomes.⁶ Multiple studies have demonstrated the importance of portable ultrasound in improving the diagnosis of first trimester bleeding, malposition, multiple gestation, and placenta previa.⁶,⁷ Other potential findings that portable ultrasound can help identify in low-resource settings include intrauterine fetal demise, anembryonic pregnancies, and non-cephalic cases.⁶,⁸ The prompt detection of these conditions allows for early management and subsequent improvements in maternal outcomes.  Even in a pandemic, it is crucial that prenatal care and early detection of prenatal  issues continue–regardless of the circumstances, pregnancies continue to happen, and the women who carry them deserve their standard of care maintained.

However, the diagnostic role of the Butterfly iQ can extend beyond prenatal care. Portable ultrasound has the potential to revolutionize medical responses during disasters, trauma, and emergency situations where resources are scarce. For example, in an Iraqi combat environment, a portable ultrasound  was used to diagnose a ruptured ectopic pregnancy.⁹ Ultrasound’s usage in pregnant mothers after the 2010 Haiti earthquake allowed for prompt diagnosis of pulmonary edema, ascites, and intrauterine fetal demise.¹⁰ Handheld ultrasounds have also been used to detect life-threatening cardiopulmonary complications, such as deep vein thrombosis (DVT), pulmonary embolism, and  pericardial effusion with tamponade.²,³ The rapid diagnosis of those complications is especially vital in pregnancy, as it is a well-established risk factor for thromboembolic disorders.¹¹ 

As hospitals around the world battle SARS-CoV2 (COVID-19), the use of Butterfly iQ and  handheld ultrasounds is proving particularly beneficial in reducing viral spread. The world is experiencing shortages in personal protective equipment, and nosocomial transmission of COVID-19 is occurring among frontline workers.¹² As a result, use of routine imaging studies within hospitals has been discouraged to reduce risk of transmission, even though ultrasound is a powerful diagnostic tool for COVID-19 pulmonary and hemodynamic  conditions.1 COVID-19 is highly contagious and may live on the surface of bulky ultrasound machines. The ultrasound machine, keyboards, cords, and wires need to be decontaminated after every patient, in a time- and resource-consuming process.¹ As medical personnel become increasingly overwhelmed and disinfection supplies become limited, there may also be less adherence to decontaminating protocols. The use of ultrasound also puts frontline workers at risk of contracting COVID-19 from prolonged close patient contact.¹,² By contrast, handheld ultrasounds can quickly be decontaminated after use and isolated within a plastic cover to minimize contamination risk.¹ During this pandemic, handheld ultrasounds may be the best option for delivering high quality care and preventing the nosocomial spread of COVID-19.¹ 

Clinical Case Examples 

The Butterfly iQ was used during the COVID-19 pandemic in a New York City hospital with a  large population of infected patients. These two cases provide insight about the Butterfly IQ  being the ideal ultrasound to reduce viral exposure.  

The first patient was a 32-year-old primigravida with dichorionic diamniotic twins. Patient’s past  medical history was significant for hypothyroidism. She had an uncomplicated prenatal course.  At week 35, her partner exhibited moderate SARS-CoV-2 symptoms and tested positive for  coronavirus. She was asymptomatic at the time. Later in the week, she had a telemedicine  appointment and exhibited mild SARS-CoV-2 symptoms (nasal congestion and a  temperature of 99.0°). During week 36, at another telemedicine appointment, she presented with  cough, fever (100.4°), fatigue, and myalgia. Although in-person visits were avoided for as long  as possible, the patient’s high risk pregnancy with twins warranted a visit during week 37. The  patient was treated as a presumptive positive coronavirus case. She was examined in a  designated COVID-19 room as the last patient of the day. Because the room didn’t have a  sonogram, the Butterfly iQ was ideal to check for twin biophysical profile, growth, position, and 

amniotic fluid index. Using the Butterfly iQ eliminated the need to transfer the patient to a  different unit. This minimized her contact with others and reduced the viral spread.  

The second patient was a 28-year-old pregnant female undergoing chemotherapy for refractory  Hodgkin’s lymphoma. During a telemedicine appointment, the patient presented with a cough and backache. Because her partner had upper respiratory symptoms, she expressed concern about being COVID-19 positive and was referred for screening. At 34 weeks, she was seen in-office. Patient tested positive for COVID-19, but symptoms had resolved. At 36 weeks, patient was examined in a designated COVID-19 room without sonogram. The Butterfly iQ was used to determine biophysical profile and amniotic fluid index. A week later, the patient was admitted for induction of labor. The Butterfly iQ was used again for ultrasound assessment upon  admission.  

Conclusion

The Butterfly iQ proved to be an efficacious and safe sonogram alternative. Using the Butterfly iQ at the patient’s bedside minimized the need to transfer patients, reducing COVID-19 exposure while  providing quality care. Its initial usage during the COVID-19 pandemic demonstrates potential benefits in other clinical scenarios, such as the ICU and maternal care in developing countries, etc..  

References:  

  1. Gibson LE, Bittner EA, Chang MG. Handheld Ultrasound Devices: An Emerging Technology to  Reduce Viral Spread during the Covid-19 Pandemic. American Journal of Infection Control.  2020. doi:10.1016/j.ajic.2020.05.041 
  2. Nelson BP, Sanghvi A. Out of hospital point of care ultrasound: current use models and future  directions. European Journal of Trauma and Emergency Surgery. 2015;42(2):139-150.  doi:10.1007/s00068-015-0494-z 
  3. Becker DM, Tafoya CA, Becker SL, Kruger GH, Tafoya MJ, Becker TK. The use of portable  ultrasound devices in low- and middle-income countries: a systematic review of the  literature. Tropical Medicine & International Health. 2016;21(3):294-311.  
  4. doi:10.1111/tmi.12657 
  5. Handheld portable ultrasound machine: Butterfly iQ. Handheld portable ultrasound machine |  Butterfly iQ. https://www.butterflynetwork.com/. Accessed June 11, 2020.
  6. Dalmacion GV, Reyles RT, Habana AE, et al. Handheld ultrasound to avert maternal and  neonatal deaths in 2 regions of the Philippines: an iBuntis® intervention study. BMC Pregnancy  and Childbirth. 2018;18(1). doi:10.1186/s12884-018-1658-8 
  7. Swanson JO, Nathan RO, Swanson DL, et al. Use of ultrasound and mHealth to improve  perinatal outcomes in low and middle income countries. Seminars in Perinatology.  2019;43(5):267-272. doi:10.1053/j.semperi.2019.03.016 
  8. Milart PHC, Prieto-Egido I, Molina CAD, Martínez-Fernández A. Detection of high-risk  pregnancies in low-resource settings: a case study in Guatemala. Reproductive Health.  2019;16(1). doi:10.1186/s12978-019-0748-z 
  9. Stamilio DM, Mcreynolds T, Endrizzi J, Lyons RC. Diagnosis and Treatment of a Ruptured  Ectopic Pregnancy in a Combat Support Hospital during Operation Iraqi Freedom: Case Report  and Critique of a Field-Ready Sonographic Device. Military Medicine. 2004;169(9):681-683.  doi:10.7205/milmed.169.9.681 
  10. Goodman A, Black L, Briggs S. Obstetrical care and women’s health in the aftermath of  disasters: The first 14 days after the 2010 Haitian earthquake. American Journal of Disaster  Medicine. 2014;9(1):59-65. doi:10.5055/ajdm.2014.0142 
  11. Devis P, Knuttinen MG. Deep venous thrombosis in pregnancy: incidence, pathogenesis and  endovascular management. Cardiovascular Diagnosis and Therapy. 2017;7(S3).  doi:10.21037/cdt.2017.10.08
  12. Gogna A, Yogendra P, Lee SHE, et al. Diagnostic Ultrasound Services During the Coronavirus Disease (COVID-19) Pandemic. American Journal of Roentgenology. October 2020:1-6. doi:10.2214/ajr.20.23167

Image 1. Normal Side. Pediatric Lung setting, demonstrates clear pleural line with sliding and z lines (aka comet tails). No indication of B lines; normal appearing lung

Image 2. Abnormal side. Additional air bronchograms further identifying the consolidated lung region. With respiration consolidated lung is partially obscured by B lines. Consolidated lung with dynamic air bronchograms

Image 3. Abnormal Side. On left of image: few B lines indicating presence of fluid in lung, irregularly appearing pleural line with sub pleural consolidation (~ 2 cm in depth). Consolidated lung area looks like liver hence the term, lung hepatization. Echogenic dots are air bronchograms; these collections move with respiration therefore they are called dynamic air bronchograms. (Note: dynamic air bronchograms = pneumonia; static air bronchogram - no movement with respiration = atelectasis)

Rachel Wong
Noel Strong MD
Taraneh Shirazian